AccountId: 011433970860
ContactId: 3d42b8b4-67ac-4027-982a-62e51bee29e5
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1398910 ms
Total Talk Time (AGENT): 378482 ms
Total Talk Time (CUSTOMER): 597722 ms
Interruptions: 3
Overall Sentiment: AGENT=0.5, CUSTOMER=1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/31/3d42b8b4-67ac-4027-982a-62e51bee29e5_20250131T13:36_UTC.wav
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[AGENT][POSITIVE] Good Morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] calling on behalf of the Test buyer together program on a recorded line for training and quality assurance. I'm looking for some benefit information for a patient.
[AGENT][POSITIVE] I don't know, it would be a pleasure to assist you with benefits this morning. What is a good callback number?
[CUSTOMER][NEUTRAL] My direct callback number is [PII]. No extension is required.
[AGENT][NEUTRAL] Thank you, [PII]. And what is the policy number for the patient?
[CUSTOMER][NEUTRAL] OK, so the patient's ID number, right?
[AGENT][NEUTRAL] Yes, sir.
[CUSTOMER][NEUTRAL] The patient's ID number is 01792121.
[AGENT][NEUTRAL] I don't know, what is the patient's name and date of birth, please?
[CUSTOMER][NEUTRAL] Patient's first name [PII]. That's spelled [PII].
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Patient's last name [PII]. That's spelled [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Thank you, [PII]. What is the date of birth?
[CUSTOMER][NEUTRAL] Patient's date of birth is [PII].
[AGENT][POSITIVE] All right, thank you, and it would be a pleasure to assist you with benefits for [PII].
[CUSTOMER][POSITIVE] Thank you so much.
[AGENT][NEUTRAL] I am showing that his policy is active.
[AGENT][NEUTRAL] Effective date is [PII].
[CUSTOMER][NEUTRAL] OK, just a, just a moment please. I'm calling to verify in-network benefits for an injection of test pier with procedure code J as in Juliet 2356 administered in a specialist office. The CPT code is 96372, and the diagnosis code is J45.51. First, could you spell out your first name and provide the first initial to your last name, please?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] My first name is [PII], first initial last name, [PII].
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Thank you so much, [PII]. It's great speaking to you. Uh, one moment please.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, so what is the policy effective date again?
[AGENT][NEUTRAL] The effective date is [PII].
[CUSTOMER][POSITIVE] Thank you so much and is the plan active?
[AGENT][NEUTRAL] It is active.
[CUSTOMER][POSITIVE] Thank you. One moment please. I'm setting up a few things up here.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK. What is the plan name?
[AGENT][NEUTRAL] It is a secondary gap policy.
[CUSTOMER][NEUTRAL] OK, could you spell that, please?
[AGENT][NEUTRAL] Secondary SEC.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] O N D.
[AGENT][NEUTRAL] A R Y.
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] And then gap, GAP.
[CUSTOMER][POSITIVE] Thank you so much. So the name of the plan is Secondary Gap, right?
[AGENT][POSITIVE] Yes, sir, that's correct.
[CUSTOMER][POSITIVE] Great, thank you so much.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And uh what type of plan is this?
[AGENT][NEUTRAL] It's a secondary policy like a supplemental.
[AGENT][NEUTRAL] It's secondary to his major medical insurance.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] No, I mean, is it a PPO, POS, or HMO plan?
[AGENT][NEUTRAL] No, sir. It's just a supplemental plan.
[CUSTOMER][NEUTRAL] Medical supplemental plan, Medicare supplement, is that correct?
[AGENT][NEUTRAL] Not Medicare supplement, it's major medical supplement.
[CUSTOMER][NEUTRAL] Why.
[CUSTOMER][NEUTRAL] Alright, just a moment please.
[AGENT][NEUTRAL] But not Medicare.
[CUSTOMER][NEUTRAL] OK, is this an indemnity plan?
[AGENT][NEUTRAL] It is not. It is a secondary plan.
[CUSTOMER][NEUTRAL] OK, one moment, please. Uh.
[CUSTOMER][NEUTRAL] One moment please, OK? I'll be right back.
[AGENT][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] Just a moment please, ma'am. um, I'm just checking a few things, OK?
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Um, so coming back to the plan type, so could you check that please if this is a, uh, PPO, POS or HMO or an inte plan or if it's an employer group Medicare plan, if you could kindly check that please.
[AGENT][NEUTRAL] It is a secondary policy to his primary insurance, Blue Cross Blue Shield.
[CUSTOMER][NEUTRAL] OK, thanks. So the type of plan is secondary policy, right?
[AGENT][POSITIVE] That's correct.
[CUSTOMER][POSITIVE] Thank you so much. And is this a commercial or Medicare Advantage plan?
[AGENT][NEUTRAL] It is through his employer.
[CUSTOMER][NEUTRAL] Uh-huh, is this a government funded plan such as Medicaid or Medicare?
[AGENT][NEGATIVE] No, sir, it is not.
[CUSTOMER][NEUTRAL] And is this a commercial plan or a Medicare Advantage plan?
[AGENT][NEUTRAL] It's a commercial plan through his employer.
[CUSTOMER][NEUTRAL] OK, commercial plan, correct?
[AGENT][NEUTRAL] Yes, sir.
[CUSTOMER][POSITIVE] Great and for billing purposes, what is the group number?
[AGENT][NEUTRAL] The group number is.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 236-333
[CUSTOMER][NEUTRAL] Uh, what is the group name?
[AGENT][NEUTRAL] The group name is Oklahoma.
[AGENT][NEUTRAL] Allerg
[AGENT][NEUTRAL] And asthma clinic.
[CUSTOMER][NEUTRAL] Uh, could you, could you repeat that please and spell that please?
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] Oklahoma.
[AGENT][NEUTRAL] O as in Oscar, K as in Kilo, L as in Lima, A as in Alpha, H as in Hotel, O as in Oscar, M as in Mike, A as in Alpha.
[CUSTOMER][NEUTRAL] I the
[AGENT][NEUTRAL] Allergy, A as in Alpha, L as in Lima, L as in Lima, E as in Echo, R as in Romeo, G as in Golf, Y as in Yankee.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And asthma, A as in Alpha, S as in Sierra, T as in Tango, H as in Hotel.
[AGENT][NEUTRAL] M as in Mike, A as in Alpha.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then the word clinic, C L I N I C.
[CUSTOMER][NEUTRAL] After Oklahoma, what is the word?
[AGENT][NEUTRAL] Allergy?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you so much. Uh, is this a Cobra plan?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It is not Cobra.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][POSITIVE] Thank you so much and does this run on benefit year or calendar year?
[AGENT][NEUTRAL] Calendar year.
[CUSTOMER][NEUTRAL] There's
[CUSTOMER][NEUTRAL] Thank you. And is this plan self-funded or fully insured?
[AGENT][NEUTRAL] It's through his employer.
[CUSTOMER][NEUTRAL] OK, so could you check that please if this is uh this plan is self-funded or fully insured?
[AGENT][NEUTRAL] It's fully insured through his employer.
[CUSTOMER][POSITIVE] Fully insured, right? Thank you so much.
[AGENT][NEUTRAL] Yes sir.
[CUSTOMER][NEUTRAL] And is referral required from primary care physician to see a specialist?
[AGENT][NEGATIVE] It is not.
[CUSTOMER][POSITIVE] Thank you and moving forward.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] uh
[CUSTOMER][NEUTRAL] Our records indicate that this member has another insurance policy. What is the name of the other insurance?
[AGENT][NEUTRAL] His primary insurance is with Blue Cross Blue Shield.
[CUSTOMER][NEUTRAL] OK, so what is the name of the other insurance?
[AGENT][NEUTRAL] Blue Cross Blue Shield.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK and.
[CUSTOMER][NEUTRAL] Just a moment, please.
[CUSTOMER][NEUTRAL] Is this a non duplication plan?
[AGENT][NEUTRAL] I'm not sure what you mean by that.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] I just.
[AGENT][NEUTRAL] We're not major medical, it's just a secondary gap policy.
[CUSTOMER][NEUTRAL] OK, so how do you coordinate benefits by non duplication of benefits or come out whole or standard coordination of benefits?
[AGENT][NEUTRAL] Standard
[CUSTOMER][NEUTRAL] OK, thank you so much and uh if the primary insurance denies, will this plan consider covering as primary?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] No, we're always secondary to the primary insurance.
[CUSTOMER][NEUTRAL] I get it, but if the primary insurance denies, will this plan consider covering as primary?
[AGENT][NEUTRAL] No, it will not. We follow the guidelines of the major medical.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, thank you so much.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Just a moment please, OK.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] What is the individual deductible for this plan and how much has been met?
[AGENT][NEUTRAL] There is no deductible on this policy. We pay toward the deductible of the major Medical.
[CUSTOMER][NEUTRAL] No deductible, right? No family deductible as well.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] That is correct. This is a medical plan, no deductible.
[CUSTOMER][NEUTRAL] OK. And what is the individual out of pocket maximum and how much has been met?
[AGENT][NEUTRAL] There's no out of pocket on this policy, that would be for the major medical policy.
[CUSTOMER][NEUTRAL] OK I mean this is a Part B drug, OK, B as in boy.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So we do not cover the medication. We can consider benefits for the administration.
[CUSTOMER][NEUTRAL] I understand, but uh what is the individual out of pocket maximum and how much has been met? Can you confirm the individual out of pocket maximum?
[AGENT][NEUTRAL] You'll have to check with the major medical on the out of pocket maximum. There's no out of pocket on this policy.
[CUSTOMER][NEUTRAL] Oh, no problem. And is there a family out of pocket?
[AGENT][NEUTRAL] There's no out of pocket on this plan.
[CUSTOMER][POSITIVE] OK, thank you so much for that. And moving on.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Hey.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Just a moment please, OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, thank you so much for your patience. Is there a true copay or coinsurance for J2356?
[AGENT][NEUTRAL] There's no co-pay or co-insurance on this policy.
[CUSTOMER][NEUTRAL] So the plan B is 100%?
[AGENT][NEUTRAL] Uh, to the benefit max for the covered, um, procedures for the policy guidelines. Yes, sir.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So the plan fee is 100% correct?
[AGENT][NEUTRAL] Uh, to 100% up to the maximum benefit of per the guidelines of the policy.
[CUSTOMER][NEUTRAL] OK, just a moment, please.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] One moment, OK? I'll be right back, ma'am.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Uh, thank you so much for your patience, ma'am. I really appreciate that so.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Is there a copay or coinsurance for the admin code 963-72?
[AGENT][NEUTRAL] There's no copay, deductible or co-insurance on the APL policy.
[CUSTOMER][NEUTRAL] OK, so the plan B is 100%.
[AGENT][POSITIVE] Up to the benefit max. Yes, sir.
[CUSTOMER][POSITIVE] OK. Thank you so much for that.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, thank you so much and moving forward is prior authorization required for test fire to be covered?
[AGENT][NEUTRAL] Prior authorization is not required.
[CUSTOMER][NEUTRAL] OK, for which code uh specifically?
[AGENT][NEUTRAL] For any code on this policy, this policy does not require authorization.
[CUSTOMER][NEUTRAL] OK, for none of the uh J code or admin code, correct?
[AGENT][NEUTRAL] For none of the procedures. It is not required on this policy. You may need to check with the Blue Cross Blue Shield Primary Insurance, but when our policy is not required,
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Got it. And for in
[CUSTOMER][NEUTRAL] OK, just to reconfirm for in network is prior authorization required for the admin code?
[AGENT][NEUTRAL] No services are required.
[AGENT][NEUTRAL] Authorization.
[CUSTOMER][POSITIVE] OK, thank you so much for that. And is predetermination required or highly recommended?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Not required.
[CUSTOMER][NEUTRAL] Is predetermination available?
[AGENT][NEUTRAL] It's not required. There's not, we don't.
[AGENT][NEUTRAL] Require predetermination nor authorization.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] No, I mean, is predetermination available? Is it a yes or no?
[AGENT][NEUTRAL] We don't, this medical policy does not.
[AGENT][NEUTRAL] Uh, provide predetermination.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK, so it's not available, right?
[AGENT][POSITIVE] That is correct.
[CUSTOMER][POSITIVE] Thank you so much. So just to confirm, this plan does not require prior authorization or predetermination for this job, correct?
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] That is correct.
[CUSTOMER][POSITIVE] Thank you so much. And can the physician buy and bill?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] We do not cover medications.
[CUSTOMER][NEUTRAL] I mean, could you check that please if the physician can buy and bill?
[AGENT][NEUTRAL] We
[AGENT][NEUTRAL] Yeah, we do not um cover medications. We could provide benefits for the administration only.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK just.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Uh, can you check that, please? I usually get a different answer for that.
[AGENT][NEUTRAL] Well, we're secondary, not major medical.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] So you might want to check with Blue Cross Blue Shield on that, but we do not cover the medication, only the administration.
[CUSTOMER][NEUTRAL] right and if the
[CUSTOMER][NEUTRAL] If the physician can buy and bill you, if you can, you can confirm, right?
[AGENT][NEUTRAL] We cannot, there's, we do not cover the medication, so there's no information regarding buying bill. You might want to check with your primary, with the insured's primary insurance on the buy and bill.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK just a moment please.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Uh, thank you so much for your patience, ma'am. I really appreciate it. Uh, are you still there?
[AGENT][NEUTRAL] I'm here.
[CUSTOMER][POSITIVE] OK. So, thank you so much. Uh, moving on.
[CUSTOMER][NEUTRAL] What is the claim's mailing address?
[AGENT][NEUTRAL] [PII] mailing address is [PII].
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And the zip code is [PII].
[CUSTOMER][NEUTRAL] They
[CUSTOMER][NEUTRAL] Could you repeat the zip code please?
[AGENT][NEUTRAL] [PII]
[CUSTOMER][POSITIVE] Thank you so much for that. And is there a pharmacy benefits managers that substances the prescription drug benefits for this plan?
[AGENT][NEUTRAL] We do not cover the the prescription nor the drugs.
[AGENT][NEUTRAL] You would need to check with the primary.
[CUSTOMER][NEUTRAL] No, I mean
[CUSTOMER][NEUTRAL] I mean, is there a pharmacy benefits manager that services the prescription drug benefits for this plan?
[AGENT][NEUTRAL] Not through this plan. You would need to check with this primary insurance.
[CUSTOMER][NEUTRAL] Is there a third party that administers the prescription drug benefits for this plan?
[AGENT][NEUTRAL] You would need to check with the insured or the primary. We're secondary and no prescription benefits.
[CUSTOMER][NEUTRAL] OK, can you check that please, uh, generally the, uh, pharmacy benefits number, uh, pharmacy benefits manager's name and phone number is generally available. Can you check that please?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] We do not have that information. You would need to check with the insured or the primary insurance.
[CUSTOMER][POSITIVE] OK. Thank you so much for that. Just a moment, please.
[CUSTOMER][POSITIVE] Thank you so much for your patience, ma'am. I really appreciate it. So, uh, OK, uh, we are done here. Can I have a reference number for this interaction, please?
[AGENT][POSITIVE] My pleasure.
[AGENT][NEUTRAL] The reference number would be my name and today's date, and I spell my name [PII].
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK
[AGENT][POSITIVE] And I, it's been a pleasure to assist you. Is there anything else I can help you with today?
[CUSTOMER][POSITIVE] Uh, thank you so much for all the help today. Have a great day. Bye.
[AGENT][POSITIVE] My pleasure. And thank you for calling APO. You have a great day as well. Take care.
[CUSTOMER][NEUTRAL] You too bye.
[AGENT][NEUTRAL] Bye bye.